SECTION 1: PERSONAL INFORMATION - Use BLOCK LETTERS and black ink to complete this form. Mark check boxes with an (X) Given Name Middle Name Surname Gender: gfedc Male gfedc Female gfedc Unknown/Other Date of Birth / / Place of Birth (Required) Suburb/Town State Country Current Residential Address (Required) Additional Details If more room is required, list on separate sheet, sign and send the sheet with this application form. Additional sheet included? gfedc Yes gfedc No Previous names (if applicable) Given Name Middle Name Surname Type: gfedc Maiden gfedc Previous gfedc Alias 5 Year Previous Address 5 Year Previous Address Contact Details Phone Private Business Mobile Email Documents Aust. Driver's Licence No. Firearms Licence No. Passport No. State/Territory State/Territory Passport Country Passport Type gfedc Private gfedc Government gfedc UN Refugee
SECTION 2: PROOF OF IDENTITY (100 - POINT CHECK) When applying for a national police history check you must provide proof of your identity with your application. You will be asked to provide personal identity documents that add up to at least 100 points. The combination of documents supplied should, as a minimum, evidence your full name and date of birth. All documents must be originals or certified true copies. Documents must be selected from the list below. Change of Name If the name you use to apply for a national police history check is different from that shown on any of your personal identity documents, you must provide evidence of the name change, e.g. Marriage or Change of Name Certificate issued by a State or Territory Registry of Births, Deaths and Marriages and Divorce papers issued by the Family Court. These documents must be originals or certified true copies and DO NOT count towards the 100-points. If you use a change of name document you must provide in Section 1 the other names you have used. You must use ONE Primary document OR At least ONE Secondary Document which MUST contain a photograph Document Type Document Points Value Points Scored PRIMARY Only one form of identification accepted from this category Birth Certificate/Birth Extract Australian Passport (Current, or expired within the previous two years, but not cancelled) Australian Citizenship Certificate International Passport (Current, or expired within the previous two years, but not cancelled) Other document of identity having same characteristics as a passport e.g. diplomatic/refugee (Photo or Signature) 70 SECONDARY Your initial Secondary Documents will score 40 points, any additional documents will be awarded 25 points each Current Licence or Permit (Government Issued) Working With Children/Teachers Registration Card ASIC/MSIC Card Public Employee Photo ID Card (Government Issued) Department of Veteran Affairs Card Centrelink Pensioner Concession Card or Health Care Card Current Tertiary Education Institution Photo ID Reference from a Doctor (must have known the applicant for a period of at least 12 months) 40 or 25 Foreign/International Driver s Licence Proof of Age Card (Government Issued) Medicare Card/Private Health Care Card Council Rates Notice Property Lease/Rental Agreement Property Insurance Papers Tax Declaration Superannuation Statement Seniors Card Electoral Roll Registration Motor Vehicle Registration or Insurance Documents Professional or Trade Association Card 25 If you wish to use more than one of these documents they must be from different organisations Utility Bills (e.g. Telephone, Gas, Electricity, Water) Credit/Debit Card Bank Statement/Passbook 25 SPECIAL PROVISIONS ONLY TO BE USED IF 100 POINT CHECK ABOVE CANNOT BE MET The full 100 point check is required when the applicant has been in Australia for longer than 6 weeks For recent arrivals in Australia (6 weeks or less proof of arrival date required) current passport 100 Aboriginal person or Torres Strait Islander resident in a remote area/community Child Under 18 Identity of applicant ordinarily resident in an isolated area verified by TWO persons recognised as Community Leaders of the community to which the applicant belongs Birth Certificate/Birth Extract Australian Passport (current, or expired within the previous two years, but not cancelled) Australian Citizenship Certificate International Passport (current, or expired within the previous two years, but not cancelled) Other document of identity having same characteristics as a passport eg. diplomatic/refugee (Photo or Signature) 70 100 TOTAL POINTS Points must equal or exceed a total of 100 OR Statement from an educational institution, signed by the principal or deputy principal, confirming that the child attends the institution (statement must be on the institution s letterhead) Total Points Scored: VERIFICATION - (OFFICE USE ONLY) I declare that I have sighted and confirmed the applicant s original or certified true copy personal identity documents and that verification has been achieved using the 100 point check. I am satisfied as to the correctness of the applicant s identity. Signature of person who has confirmed 100pts of ID: Printed name of person who has confirmed 100pts of ID: Date: / /
SECTION 3: ACCREDITED AGENCY DETAILS Accredited Agency (Legal Name): MERCURY SEARCH & SELECTION PTY LTD t/a fit2work.com.au ABN: 86 080 799 720 SECTION 4: AUTHORISATION TO DISCLOSE PERSONAL INFORMATION Is the result of the national police history check to be forwarded/disclosed only to the accredited agency named in Section 3 above? gfedc Yes gfedcb No If No: I authorise the result of the national police history check to be forwarded/disclosed to the following employer/organisation: Employer/Organisation (Legal Name): Cerebral Palsy Alliance - Volunteers ABN: 45000062288 SECTION 5: PURPOSE OF THE NATIONAL POLICE HISTORY CHECK Provide details of relevant position/entitlement, place of work and whether you have contact with vulnerable groups. e.g. Client Services Officer in a call centre, Janitor at a school, Nurse in aged care facility with direct care of disabled & aged persons or Flight Attendant with direct care of children). Purpose/Description of Duties SECTION 6: CONSENT TO OBTAIN PERSONAL INFORMATION National Police History Check I, hereby: Given Names (Current) Family Name(Current) 1. acknowledge that I have read the General Information sheet and understand that Spent Convictions legislation (however described) in the Commonwealth and many States and Territories protects spent convictions from disclosure; 2. understand that the national police history check for which I am applying may be in a category for which exclusions from Spent Convictions legislation may apply; 3. have fully completed this Form, and the personal information I have provided in it relates to me, contains my full name and all names previously used by me, and is correct; 4. acknowledge that the provision of false or misleading information is a serious offence; 5. acknowledge that the Accredited Agency named in Section 3 above is collecting information in this Form to provide to the CrimTrac Agency (an Agency of the Commonwealth of Australia) and the Australian police agencies; 6. consent to: i. the CrimTrac Agency disclosing personal information about me to the Australian police agencies; ii. the Australian police agencies disclosing to the CrimTrac Agency, from their records, details of convictions and outstanding charges, including findings of guilt or the acceptance of a plea of guilty by a court, that can be disclosed in accordance with the laws of the Commonwealth, States and Territories and, in the absence of any laws governing the disclosure of this information, disclosing in accordance with the policies of the police service concerned; iii. the CrimTrac Agency providing the information disclosed by the Australian police agencies to the accredited agency named in Section 3 above, in accordance with the laws of the Commonwealth; and iv. where applicable, the accredited agency named in Section 3 above disclosing to the employer/organisation named in Section 4 above personal information about me to assess my suitability in relation to my employment/entitlement; and 7. acknowledge that any information provided by me on this Form, relates specifically to the purpose identified in Section 5 above; 8. acknowledge that any information provided by the Australian police agencies or the CrimTrac Agency, relates specifically to the purpose identified in Section 5 above; 9. acknowledge that personal information that I provide in this Form may be disclosed to the Accredited Agency named in Section 3 above (including contractors or related bodies corporate) located in Australia or overseas for administrative purposes; and 10. acknowledge that it is usual practice for an applicant s personal information to be disclosed to Australian police services for them to use for their respective law enforcement purposes including the investigation of any outstanding criminal offences. Note: The information you provide on this Form, and which the CrimTrac Agency provides to the accredited agency named in Section 3 above, on receipt of the Form, will be used only for the purpose stated above unless statutory obligations require otherwise. Applicant's Signature: Date: / / Parent/Guardian Consent - If you are under 18 years of age provide consent below from a parent /guardian. Parent/Guardian Signature Office Use Date: / / Parent/Guardian name printed in full Check Urgency: gfedc Normal gfedc Urgent Type of Check: gfedc Employee gfedc Volunteer Applicant Role: Department: Supervisor: Other Info:
GENERAL INFORMATION GENERAL INFORMATION This Form is used as part of the assessment process to determine whether a person is suitable for employment or other engagement for work or other entitlement. Unless statutory obligations require otherwise, the information provided on this Form will not be used without your prior consent for any purpose other than in relation to the assessment of your suitability. You may be required to complete another consent form in the future in relation to employment in other positions. NATIONAL POLICE HISTORY CHECK A national police history check is an integral part of the assessment of your suitability. You should note that the existence of a record does not mean that you will be assessed automatically as being unsuitable. Each case will be assessed on its merit, so it is in your interest to provide full and frank details in the form. Information extracted from this Form will be forwarded to the CrimTrac Agency and other Australian police agencies for checking action. By signing this Form you are consenting to these agencies accessing their records to obtain and disclose police history information that relates to you to: (i) the accredited agency named in Section 3 above; and (ii) where applicable the employer/organisation named in Section 4 above. Police history information may include outstanding charges, and criminal convictions/findings of guilt recorded against you that may be disclosed according to the laws of the relevant jurisdiction and, in the absence of any laws governing the release of that information, according to the relevant jurisdiction's information release policy. It is usual practice for an applicant s personal information to be disclosed to Australian police agencies for them to use for their respective law enforcement purposes including the investigation of any outstanding criminal offences. SPENT CONVICTIONS SCHEMES The aim of spent convictions legislation is to prevent discrimination on the basis of certain previous convictions. Spent convictions legislation limits the use and disclosure of older, less serious convictions and findings of guilt. Spent convictions of specific offences will be released where the check is required for certain purposes regardless of how old they are. Each Australian police agency will apply the relevant Spent Convictions legislation/information release policy prior to disclosure. If further information or clarification is required please contact the individual police agencies directly for further information about their release policies and any legislation that affects them. Western Australia Under the provisions of Section 7(1) of the Spent Convictions Act 1988 (WA) only lesser convictions can be spent by Western Australia Police, after a time period of 10 years plus any term of imprisonment that may have been imposed. A lesser conviction is one for which imprisonment of 12 months or less, or a fine of less than $15,000 was imposed. All other convictions, such as serious convictions applicable under Section 6 of the Act can only be spent by applying to the District Court. At the time of sentencing, the Court may make a spent conviction order under the Sentencing Act 1995 (WA) that the conviction is a spent conviction for the purposes of the Spent Convictions Act 1988 (WA). South Australia Release of information on a National Police Check is governed by the South Australian Spent Convictions Act 2009. It is an offence to release information regarding the convictions of a person if those convictions are deemed to be spent under the Act. A spent conviction is one that cannot be disclosed or taken into consideration for any purpose. Eligible convictions become spent following a 10 year conviction and proven offence-free period for adults, and a 5 year conviction and proven offence-free period for juveniles. The Act defines a conviction as: i). a formal finding of guilt by a Court; ii). a finding by a Court that an offence has been proved. Certain convictions can never be spent. These include but are not limited to: i). convictions of sex offences; ii). convictions where a sentence is imposed of more than 12 months imprisonment for an adult, or 24 months imprisonment for a juvenile. Schedule 1 of the Act sets out a number of exceptions to the rule where spent convictions can be released. Some examples of this include: i). the care of children; ii). the care of vulnerable people (including the aged and persons with a disability, illness or impairment); iii). activities associated with statutory character tests for licensing Interstate offences are released in accordance with that State or Territory's spent conviction / rehabilitation legislation and policy. Intelligence-type information is not released. 1 Australian Federal Police, The New South Wales Police Force, Victoria Police, Queensland Police Service, South Australia Police, Western Australia Police, Tasmania Police Service, Northern Territory Police Force. 2 Applicable spent conviction legislation, as amended from time to time. Commonwealth Part VIIC of the Crimes Act 1914 (Cth) deals with aspects of the collection, use and disclosure of old conviction information. The main element of this law is a Spent Convictions Scheme. The aim of the Scheme is to prevent discrimination on the basis of certain previous convictions, once a waiting period (usually 10 years) has passed and provided the individual has not re-offended during this period. The Scheme also covers situations where an individual has had a conviction quashed or has been pardoned. A spent conviction is a conviction of a Commonwealth, Territory, State or foreign offence that satisfies all of the following conditions: i). it is 10 years since the date of the conviction (or 5 years for juvenile offenders); AND ii). the individual was not sentenced to imprisonment or was not sentenced to imprisonment for more than 30 months; AND iii). the individual has not re-offended during the 10 years (5 years for juvenile offenders) waiting period; AND iv). a statutory or prescribed exclusion does not apply. (A full list of exclusions is available from the Office of the Australian Information Commissioner). The law affects Commonwealth authorities in the following ways: i). a person with a conviction protected by Part VIIC does not have to disclose that conviction to any person, including a Commonwealth authority, unless an exclusion applies; ii). Commonwealth authorities are prohibited from accessing, disclosing or taking into account spent convictions of Commonwealth offences. Part VIIC and Crimes Regulations 1990 provide for statutory or regulatory exclusions that will prevent certain Commonwealth convictions from being spent in certain circumstances. Queensland Under Queensland s Criminal Law (Rehabilitation of Offenders) Act 1986 a conviction automatically becomes spent upon completion of the prescribed (rehabilitation) period. This period is: 1> 10 years for indictable offences where the offender was an adult at the time of conviction; and 2> 5 years for other (summary offences or where the offender was a juvenile).where a person is convicted of a subsequent offence (an offence other than a simple or regulatory offence) during the rehabilitation period, the period runs from the date of the subsequent conviction. Convictions where the offender is sentenced to more than 30 months imprisonment (whether or not that sentence is suspended) are excluded from the regime. Once the rehabilitation period has expired, it is lawful for a person to deny (including under oath) that the person has been convicted of the offence, and the conviction must be disregarded for occupational licensing purposes (subject to certain exceptions, see below). It is unlawful for any person to disclose the conviction unless: (i) the convicted person consents; (ii) the Minister has granted a permit authorising disclosure (where there is a legitimate and sufficient purpose for disclosing); (iii) the disclosure is subject to an exemption. Victoria Police For the purposes of employment, voluntary work or occupational licensing/registration, police may restrict the release of a person s police record according to the Victoria Police Information Release Policy. If you have a police record the Information Release Policy may take into account the age of the police record and the purpose for which the information is being released. If 10 years have elapsed since you were last found guilty of an offence, police will, in most instances, advise that you have no disclosable court outcomes. However, a record over 10 years may be released if: (i) it includes a term of imprisonment longer than 30 months; (ii) it includes a serious, violent or sexual offence and the check is for the purpose of working with children, elderly people or disabled people; (iii) it is in the interests of crime prevention or public safety. Findings of guilt without conviction and good behaviour bonds may be released. Recent charges or outstanding matters under investigation that have not yet gone to court may also be released. New South Wales In New South Wales the Criminal Records Act 1991 (NSW) governs the effect of a person s conviction for a relatively minor offence if the person completes a period of crime-free behaviour, and makes provision with respect to quashed convictions and pardons. A quashed conviction is a conviction that has been set aside by the Court. A pardon means a free and absolute pardon that has been granted to a person because he/she was wrongly convicted of a Commonwealth, Territory, State or foreign offence. In relation to NSW convictions, a conviction generally becomes a spent conviction if a person has had a 10 year crime-free period from the date of the conviction. However, certain convictions may not become spent. These include: (i) where a prison sentence of more than 6 months has been imposed (periodic or home detention is not considered a prison sentence); (ii) convictions against companies and other corporate bodies; (iii) sexual offences pursuant to the Criminal Records Act 1991; and (iv) convictions prescribed by the Regulations PROVISION OF FALSE OR MISLEADING INFORMATION You are asked to certify that the personal information you have provided on this form is correct. If it is subsequently discovered, for example as a result of a check of police records, that you have provided false or misleading information, you may be assessed as unsuitable. It is a serious offence to provide false or misleading information
Persons Authorised to Certify Documentation Persons Authorised to Certify Documentation In a situation where you are unable to bring your original 100 points of ID to be physically sighted by the organisation, you may have copies officially certified by a person listed below. Documents only need to be certified if you are unable to provide the original documents to the organisation performing the check. 1. Only persons holding positions identified below are authorised to certify documentation for the undertaking of a National Police History Check (NPHC). The exception to the list is where a potential conflict of interest may arise, such as certifying a family members identification 2. Authorised persons, in certifying a NPHC document, MUST: 1. Sight ORIGINAL documentation 2. Verify that the photocopy is a true and accurate record of the original document 3. Verify that the photographic identification is a true and accurate likeness of the applicant 4. Declare on the document to be signed that it is a true and accurate record of the original document 5. Sign and date each photocopy as a true and accurate record of the original document 6. Print your name and position (authorised position below) on each document to be certified 3. Applicants must ensure that documents must be certified in accordance with the above - Australian Lawyer (Legal Profession Act 2004) - Registered Medical Practitioner - Pharmacist - Member of the police force - Principal/teacher in the teaching service - Registered Nurse - Secretary of building society - Councillor of a Municipality - Public Notary - Veterinary Practitioner - Justice of the Peace, Bail Justice or Register of the magistrate s Court - Permanent employee of Australia Post with 5 or more years continuous service - State non-executive public service employee (Grade 2-6) - Commonwealth exec public service employment (Level 1, 2 or 3) - Commonwealth non-exec public service employee (APS 2-6) - Accountant (member of the ICA,ASA or NIA) - Registered Dentist (Dental Practice Act 1999) - Bank manager of employee with 5 or more years of continuous service - Minister of Commonwealth or State Parliament - Casino special employee